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. Author manuscript; available in PMC: 2026 Mar 7.
Published in final edited form as: Int J Eat Disord. 2023 Aug 8;56(11):2142–2148. doi: 10.1002/eat.24041

“But the reality is it’s happening”: A qualitative study of eating disorder providers about psilocybin-assisted psychotherapy

Amanda E Downey 1,2, Maxine Boyd 3, Anita V Chaphekar 1, Joshua Woolley 2,4, Marissa Raymond-Flesch 1,5
PMCID: PMC12965192  NIHMSID: NIHMS2143491  PMID: 37551650

Abstract

Objective:

This study invited providers who care for patients with eating disorders to inform engagement, communication, and collaboration with psilocybin-assisted psychotherapy interventions.

Method:

Medical and mental health providers who treat patients with eating disorders were recruited via professional referral networks and participant driven sampling from across California to participate in 1 of 5 focus groups. Discussion topics included prior knowledge of psychedelic therapy, interest/concerns related to psilocybin therapy, and opportunities for collaboration. Study team members completed iterative rounds of coding with a grounded theory approach.

Results:

32 participants reported a range of familiarity with psychedelics. Some raised concerns about the risks of administering psilocybin to malnourished patients and to those with psychological comorbidities. Despite these concerns, participants were hopeful to see psilocybin therapy as a treatment for patients with eating disorders. In anticipating challenges, providers had concerns about equity in access to care among publicly insured and non-English speaking patients. They requested opportunities for continuing education about psilocybin therapy.

Discussion:

Our findings demonstrate provider interest in psilocybin therapy for the treatment of patients with eating disorders. As psilocybin therapy interventions are developed, providers caring for patients with eating disorders value collaboration to improve longitudinal patient outcomes.

Keywords: Eating disorders, psychedelic-assisted psychotherapy, anorexia nervosa, psilocybin

Introduction

The most promising, evidence-based psychotherapy treatments for anorexia nervosa (AN) yield recovery in less than half of those treated and no medications have proven efficacious (Cassioli et al., 2020; Crow, 2019; Watson & Bulik, 2013). Novel treatments are urgently needed to address this increasingly prevalent, difficult to treat, and often fatal condition. Psilocybin therapy, which typically includes a brief course of psychotherapy paired with one or two administrations of psilocybin (a classic psychedelic), shows promise as a treatment for many mental health conditions with long-lasting improvements in anxious (Griffiths et al., 2016; Moreno et al., 2006), depressive (Carhart-Harris et al., 2018; Griffiths et al., 2016), and addictive behaviors (Bogenschutz & Johnson, 2016; Johnson et al., 2017). Naturalistic and pilot studies utilizing psychedelics in adults with eating disorders show early signals of promise, and controlled trials are now underway (Brewerton et al., 2022; Peck et al., 2022, 2023; Spriggs et al., 2021). As psilocybin-assisted therapy was granted breakthrough status by the FDA for treatment-resistant depression and major depressive disorder, the field must engage community stakeholders in the care of patients with eating disorders in anticipation of both emerging clinical trials and potential FDA approval for this indication.

Eating disorder providers will need to understand for whom this therapy will confer benefit, how to effectively collaborate with the psilocybin therapy team, and which therapeutic approach to utilize for ongoing treatment. The confidence of these providers in supporting continued change resulting from psilocybin therapy is likely to shape long term clinical outcomes. No studies to date have explored how intra- and post-trial care can best be facilitated between the psilocybin therapy study team and community providers.

Implementation science integrating stakeholders allows researchers to pragmatically refine research interventions for successful adaptation and implementation in complex, real world settings, increasing impact by adding contextual and cultural knowledge (Khodyakov et al., 2011; Price et al., 2022; Triplett et al., 2022). Despite the surge in psychedelic therapy clinical trials, stakeholder engagement is scantly reported and only recently are frameworks emerging for patient and public involvement (Close et al., 2021). Our study invited stakeholders in the care of patients with eating disorders to inform emerging clinical trials with the goal of successful adoption in real world clinical settings. The aims of these focus groups were to (1) understand stakeholder beliefs about psilocybin therapy for the treatment of eating disorders, (2) understand perceived barriers and challenges in caring for patients with eating disorders before, during, and following psilocybin therapy, and (3) identify the clinical information and collaborative support that these stakeholders would want in the context of referring patients to, or receiving patients from, a trial of psilocybin therapy.

Method

We conducted five Zoom-based focus groups with stakeholders from across California who care for patients with eating disorders, including outpatient therapists, therapists in higher levels of care (intensive outpatient programs, partial hospitalization programs, residential programs, and inpatient programs) as well as medical and psychiatric providers.

Participants

Eligible participants were licensed to provide medical or psychotherapeutic care to patients with eating disorders in the state of California, able to speak English, able to provide verbal or written participant consent, and able access to the internet and utilize Zoom. Participants with formal training in ketamine administration and/or ketamine therapy were assigned to a designated focus group.

The study team conducted initial recruitment via professional referral networks of psychotherapists, psychiatrists, nurse practitioners, and medical providers who focus on the care of patients with eating disorders across California. Participant driven sampling (“snowball sampling”) further increased the sample size.

Data Collection

We completed five focus groups (N=32). Participants were asked to complete a demographic questionnaire prior to the focus group. Focus groups were 60 to 90 minutes long and conducted virtually via the Zoom platform. We recruited six to nine participants per group. The moderators guide explored themes including knowledge of and attitudes towards the use of psilocybin therapy for the treatment of AN, information participants need to feel confident referring for psilocybin therapy, and participant’s trusted sources of professional educational and training. After adequate exploration of these themes, the moderator facilitated a discussion about the format of a typical psilocybin therapy clinical trial. The lead moderator was a Latina attending adolescent medicine physician experienced in focus group moderation, with 11 years experience caring for patients with eating disorders, with assistance from other study team members: one Asian female adolescent medicine fellow (three years clinical eating disorder experience), one White female attending child and adolescent psychiatrist (six years clinical eating disorder experience) and one White female undergraduate student (no clinical eating disorder experience). Participants were compensated with a $75 gift card. The Institutional Review Board at the University of California, San Francisco approved all study procedures.

Analysis

Focus group recordings were professionally transcribed and quality checked by one of the study team members. A grounded theory approach was utilized in which the research team worked to identify and set aside preconceptions through the following strategies: including team members who are new to the subject matter (no prior engagement with patients with eating disorders or their providers), sharing reflective memos about common themes and how they do or do not challenge the researchers’ preconceived beliefs about the subject matter, and searching for counter examples for each identified code (Basics of Qualitative Research, 2023; Glaser & Strauss, 2017). Team members present at each group created memos of themes that arose. Sample size was deemed adequate at thematic saturation when no new themes were identified. No new themes emerged after the third focus group, though two additional focus groups were completed to assure saturation. Four authors (Downey, Boyd, Chaphekar, Raymond-Flesch) independently read all transcripts, including those focus groups they did not attend, expanded their initial memos of themes, and identified the most common themes across memos. In iterative rounds of analytic meetings authors distilled codes into a codebook, applied the code book to two transcripts, and reviewed and refined codes to assure interrater reliability. Differences in thematic identification and application were discussed and revised until the team came to consensus.

Results

See Table 1 for demographic information. The codebook and exemplar quotes are provided as supplementary material. Results presented here represent a narrative summary of how key codes interrelate in ways that apply to future clinical and research engagement.

Table 1.

Demographic characteristics of focus group participants (n=28)

Age, (mean±SD) 48 (10.8)
Gender
 Male 1
 Female 23
 Nonbinary 4
Ethnicity
White 23
Latinx 1
Asian 4
Highest degree earned, n(%)
 LCSW 2 (7.1)
 LMFT 4 (14.3)
 MD/DO 6 (21.4)
 PhD 8 (28.6)
 PsyD 1 (3.6)
 Othera 7 (25.0)
Practice setting, n(%) b
 Academic Institution 9 (23.7)
 Private Practice 13 (34.2)
 IOP/PHP Programc 8 (21.1)
 Residential Program 4 (10.5)
 Otherd 4 (10.5)
Years experiencee, (mean±SD) 3.4±0.90
Therapy Modalities, n(%) b
 Family based treatment 14 (28.6)
 Cognitive behavioral therapy 13 (26.5)
 Dialectical behavioral therapy 9 (18.4)
 Medical monitoring 6 (12.2)
 Otherf 7 (14.3)
Experience with psychedelic-assisted therapy, n(%)
 No previous experience 0 (0)
 Print media 9 (32.1)
 Podcast/Webinar 3 (10.7)
 Anecdotal 7 (25.0)
 Certified in this therapy 1 (3.6)
 Completed Ketamine therapy training 2 (7.1)
 Otherg 8 (28.6)
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a.

Responses of Other included: MSW, AMFT, MSN ANP/PMHNP, and NCC

b.

N is greater than 28 as selection of more than one answer choice was allowed

c.

IOP = intensive outpatient program; PHP = partial hospitalization program

d.

Responses of Other included: outpatient clinic

e.

Years experience working with patients with eating disorders

f.

Responses of Other included: IFS, mentalization based treatment, ketamine-assisted psychotherapy, and ACT. Responses of Other included: attendance of trainings without certification.

Across all focus groups participants were eager to explore more treatment options for patients with eating disorders. Caution about psilocybin therapy in patients with eating disorders was common due to the high burden of comorbid behavioral health conditions, as well as their unique medical vulnerabilities. In addition, a common concern across focus groups was the profit motive driving private companies to promote psychedelic therapies, and how this financial incentive combined with unrealistic patient expectations might lead to irresponsible implementation.

Participants shared anecdotes of patients, colleagues, friends, and family members who had therapeutic experiences with psychedelics through clinical trainings, at international retreats, or in “underground” experiences; all described a sense of hope related to the positive outcomes they had heard about these experiences. One participant described her patients’ “wild interest” in psilocybin therapy, reflecting generally how our participants commonly expressed that their patients are asking about, or already engaging with, psychedelic substances; many commented that the lack of peer-reviewed data makes it difficult to advise patients in responsible and therapeutic use.

Across focus groups, participants expressed a sense of responsibility or protectiveness of vulnerable populations with eating disorders, including the potentially limited access to psilocybin therapy for those with public insurance. Other participants expressed concerns about access for non-English speaking patients and patients from diverse racial and ethnic backgrounds. Many advocated for treatments inclusive of patients with AN-binge/purge subtype or atypical AN, worrying that this treatment would be exclusively utilized for those with low-weight and/or restrictive subtypes of AN.

Legal and ethical responsibility for negative experiences during psilocybin therapy was a common concern among participants. Some were particularly concerned about potential legal liability, “...even though they would no longer be our client or patient during this time and [the psychedelic therapy team] would be liable, as somebody who has worked with them, I do feel this responsibility...even if they don’t come back at me and say like, ‘I’m going after you, this was a terrible recommendation.’”

Providers in this study requested additional guidance and resources from psilocybin therapy teams and researchers at all stages of patient involvement. Most wanted general information about psychedelic therapy in order to accurately inform their patients about the process. The providers in this study had many questions about how to engage with psilocybin therapy teams treating their patients. Some were concerned about preserving their therapeutic relationships and supporting their patients who enter psilocybin therapy. Some participants envisioned their roles as gatekeepers while others wanted to provide collateral information to the psilocybin therapy team as their patients enter treatment. One therapist noted, “I will be a part of the team whether I’m on the faculty or not.” Participants also requested a provider-to-provider handoff or a written summary prepared by their patients at the end of the psilocybin therapy to inform treatment goals moving forward. Finally, many providers wanted guidance about the therapeutic approaches to employ following psilocybin therapy, “As clinicians, we’re all trained differently and have different therapeutic approaches to our work, but I do wonder if there are particular therapeutic modalities that would be more helpful or more effective in supporting those long-term outcomes.” See Table 2 for participant-requested supports before, during, and after psilocybin therapy.

Table 2:

Additional education and collaboration requested by participants

Prior to Psychedelic Therapy During Psychedelic Therapy Following Psychedelic Therapy
• Guidance on which clients to refer for psychedelic therapy.
• Information about any locally occurring study protocols to facilitate anticipatory guidance for patients and families.		 • Opportunity for the outside provider to give collateral information to the psychedelic therapy team.
• Opportunity for outside providers to support clients formally or informally for the duration of their psychedelic therapy.
• Verbal updates from the psychedelic therapy treatment team including a discussion about the psychedelic therapy outcomes at the end of treatment.
• Written summary statement prepared by the client with support from the psychedelic therapy team.		 • Intermittent consultation regarding:
 ∘ Guidance on expected short and long-term adverse events and assistance in identifying when adverse events are due to the psychedelic therapy.
 ∘ Strategies for supporting ongoing integration of the psychedelic experience.
• Formal consultation group for providers managing clients who have completed psychedelic therapy programs or studies.
• Ongoing groups for patients who have completed psychedelic therapy.
Resources useful to outpatient providers throughout the psychedelic therapy process
• Access to curated list of scholarly publications maintained by academic centers conducting psychedelic therapy trials including:
 • Data on the safety and efficacy of psychedelics and psychedelic therapy
 • Data on best practices for psychotherapy following psychedelic therapy for eating disorders and other common comorbidities.
• Talks, workshops, podcasts, or continuing education programming on general information about psychedelic therapy from reputable sources.
• Access to curated list of high-quality psychedelic therapy training programs.
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Discussion

Providers caring for patients with eating disorders were cautiously optimistic about novel treatment modalities, like psilocybin therapy, for the treatment of AN. While caution is warranted, well-established organizations like the U.S. Department of Veterans Affairs makes access to innovative and high-quality clinical trials a strategic priority to provide access to cutting edge treatments and to ensure the most meaningful positive effects possible for its patients (Strategic Priorities for VA Research, 2021). Data-driven dissemination of information about psilocybin therapy for other indications is likely to generate increased knowledge and positive attitudes about the intervention among eating disorder providers, broadly consistent with findings from implementation science in psychological interventions (Purtle et al., 2020). Our study builds upon prior work examining therapist openness to inform eligible patients about psilocybin therapy by also understanding community provider needs prior to, during, and after the clinical trial. As patients are sourcing psilocybin therapy both in clinical trials and in unregulated settings, providers report an ethical imperative to facilitate safe and responsible engagement.

While previous studies have described therapist openness to referral and attitudes towards psychedelic therapies, our study newly uncovers stakeholder beliefs around partnership with the team implementing psilocybin therapy (Davis et al., 2022; Meir et al., 2023; Meyer et al., 2022). Even without a formal role in the intervention, community providers frame the treatment for patients, provide collateral information, and carry forward the therapeutic work. Outside of the context of clinical trials, their patients are already seeking or using psychedelics; as such, they desire to operate from a framework of data-informed knowledge, harm reduction, and responsible engagement with psilocybin therapy to best advise their patients. To meet this need, data from clinical trials need to be rapidly translated into best practices and disseminated to community eating disorder providers. Further studies should rigorously test the therapeutic modalities best suited for post-psilocybin therapy care, as this was a common concern among our participants.

In line with the implementation science literature, our study finds that providers desire that psilocybin clinical trials enroll diverse patients with eating disorders (Heller et al., 2014; McFarlane et al., 2022; Nueces et al., 2012). Despite increasing recognition of disordered eating in youth of all races, genders, and socioeconomic statuses, the longstanding stereotype of eating disorders as a predominantly white, female disorder continues to bias healthcare providers and contributes to systemic inequity within clinical trials and the healthcare system (Accurso et al., 2021; Chaphekar et al., 2023; Nagata et al., 2020; Roberts et al., 2021; Sonneville & Lipson, 2018). Major randomized trials of patients with eating disorders include predominantly white samples or do not report ethnic/racial demographics (Lock et al., 2010; Attia et al., 2019). Even more striking is the underrepresentation of minorities in modern psychedelic clinical trials. From 1993 to 2017, only 2.1% of psychedelic therapy trial participants identified as Latinx (Michaels et al., 2018). Improving diversity in clinical trials is necessary to build trust in and cement the generalizability of clinical interventions (Kelsey et al., 2022). To our knowledge, this is the first qualitative study to explore community stakeholder attitudes towards diversity in recruitment for psychedelic clinical trials in patients with eating disorders and underscores the need to understand how to recruit diverse populations.

Our study has several limitations. Our sample was limited to providers in the state of California which trends toward liberal drug policies. Additionally, our sample size was small (N=32) and predominantly female (n=23). A larger and more diverse sample may yield different findings. As personal experience with psychedelics correlates to more positive attitudes towards this therapy (Meyer et al., 2022), future studies may screen for personal history of psychedelic use. Additional qualitative work should consider the inclusion of caregivers and patients with lived eating disorder experience to foster trust, learning, purpose and inclusivity as outlined in initial frameworks for supporting patient and public involvement in psychedelic research (Close et al., 2021).

Conclusion

Psilocybin therapy study teams can partner with community providers as critical team players. Eating disorder providers have interest in psilocybin therapy for their patients and provide considerations to guide the design of emerging clinical trials. As research protocols and psilocybin therapy interventions are developed, the perspectives of providers who refer patients to care and resume care following psilocybin therapy should be explored to accelerate successful implementation.

Supplementary Material

Supplementary Material

Public Significance:

This study invited healthcare providers of patients with eating disorders to discuss their thoughts around the use of psilocybin-assisted psychotherapy in this population. Findings will help inform emerging psilocybin therapy clinical trials with the goal of successful translation and adoption in real world clinical settings.

Funding Sources:

Mary Rita Crittenden Fund at the University of California San Francisco, Division of Adolescent and Young Adult Medicine.

Footnotes

Conflicts of interest statement: The authors have no conflicts to disclose.

Availability of Data, Materials and Code:

The data that support the findings of this study are available on request from the corresponding author, AED. The data are not publicly available due to confidentiality restrictions; e.g., they contain information that could compromise the privacy of research participants.

Data Sharing:

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material
NIHMS2143491-supplement-Supplementary_Material.docx (19.2KB, docx)

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author, AED. The data are not publicly available due to confidentiality restrictions; e.g., they contain information that could compromise the privacy of research participants.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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